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1.  Large mucinous neoplasm of the appendix mimicking adnexal mass in a postmenopausal woman 
Highlights
•Appendiceal tumors are rare, late-diagnosed neoplasms that may not be differentiated from adnexal masses.•Pre-operative diagnosis remains difficult and it can be mimicking adnexal mass.•It may be asymptomatic and remain undiagnosed until surgery.•Appendiceal tumor kept in mind in a patient with diagnosed adnexal mass, especially patient had a non-specific clinical symptoms, laboratory and radiologic findings.
INTRODUCTION
Appendiceal tumors are rare, late-diagnosed neoplasms that may not be differentiated from adnexal masses even by advanced imaging methods and other diagnostic procedures. They may be asymptomatic and remain undiagnosed until surgery.
PRESENTATION OF CASE
We report a case of 81-year-old postmenopausal woman presented with abdominal pain. A magnetic resonance imaging revealed right adnexal mass. Laparotomy was performed and detected a 12 cm × 9 cm mucinous tumoral mass arising in the appendix. An appendectomy and a right hemicolectomy with ileo-transverse anastomosis were performed. Histopathological examination was revealed appendiceal mucinous neoplasm with low malignancy potential.
DISCUSSION
Gastrointestinal tumors such as appendiceal tumors can mimicking adnexal mass. Therefore, appendiceal tumor kept in mind in a patient with diagnosed adnexal mass, especially patient had non-specific clinical symptoms, laboratory and radiologic findings.
CONCLUSION
Gastrointestinal tumors such as appendiceal tumors kept in mind in a patient with diagnosed adnexal mass.
doi:10.1016/j.ijscr.2014.11.050
PMCID: PMC4275782  PMID: 25498566
Adnexal mass; Appendiceal neoplasm; Diagnosis
2.  Acute compartment syndrome secondary to disruption of the perforating branch of the peroneal artery following an acute inversion injury to the ankle 
Highlights
•Vascular disruption and compartment syndrome, although rare, can be severe sequelae of an inversion ankle injury.•The perforating branch of the peroneal artery passes anteriorly through a hiatus in the interosseous membrane, and is susceptible to stresses in inversion injury of the ankle.•Acute compartment syndrome related to vascular lesions may rapidly present in hours after ankle sprain.
INTRODUCTION
Although ankle sprain by inversion is common in daily practice, acute compartment syndrome following ankle inversion injury is unusual. Only a few cases of this uncommon entity have been reported.
PRESENTATION OF CASE
This report describes a case of acute compartment syndrome following severe inversion of an ankle injury secondary to disruption of the perforating branch of the peroneal artery 3 h after the trauma. Although emergent fasciotomy was performed, residual weakness of ankle dorsiflexion still presented six months after surgery.
DISCUSSION
To the best of our knowledge, this case is the third in literature on an acute compartment syndrome following severe inversion ankle injury secondary to disruption of the perforating branch of the peroneal artery.
CONCLUSION
This report underscores the importance of considering compartment syndrome when individual has an inversion ankle injury, even when no fracture exists.
doi:10.1016/j.ijscr.2014.11.059
PMCID: PMC4275801  PMID: 25460492
Ankle sprain; Acute compartment syndrome
3.  Percutaneous reduction and flexible intramedullary nailing for monteggia fracture in a skeletally mature patient 
INTRODUCTION
Monteggia lesions are defined as a fracture of the proximal ulna with an associated radial head dislocation. Management of these injuries varies depending upon the patient population, ranging from non-operative treatment with closed reduction and immobilization to surgical fixation. Percutaneous techniques of radial head reduction are often reserved for skeletally immature patients.
PRESENTATION OF CASE
In this case report, a 14-year-old female presented with left elbow pain three days after a fall. Radiographs and CT images from an outside hospital revealed a displaced left radial head fracture and a non-displaced proximal olecranon fracture, consistent with a Monteggia equivalent fracture. The patient underwent percutaneous reduction and internal fixation of the radial head with a flexible intramedullary nail (Metaizeau technique), and open reduction and internal fixation of the olecranon. She developed a 25 degree left elbow flexion contracture and, five months after her index procedure, underwent arthroscopic release and removal of hardware. The radial head reduction was near anatomic and she regained full extension.
DISCUSSION
This report demonstrates that percutaneous reduction with intramedullary nailing and fixation techniques can be performed successfully in skeletally mature patients.
CONCLUSION
Given their less invasive nature, we recommend attempting percutaneous interventions in some skeletally mature individuals for fracture reduction and fixation.
doi:10.1016/j.ijscr.2014.11.057
PMCID: PMC4275958  PMID: 25460489
Metaizeau; Percutaneous; Skeletally mature; Monteggia
4.  Colonic perforation by a large gallstone: A rare case report 
Highlights
•An 86-year-old woman with a history of cholelithiasis presented with abdominal pain and nausea.•Imaging demonstrated pneumobilia, bowel dilation, and a 3.5 cm gallstone in the sigmoid colon.•Conservative management, enemas, and an attempt to ensnare the gallstone by colonoscopy, failed.•The patient underwent a sigmoid resection and a Hartmann’s procedure for gallstone perforation.•She was discharged after a complicated post-operative course and has returned to her baseline.
INTRODUCTION
Herein we present the case of an 86-year-old woman with gallstone perforation of the sigmoid colon.
PRESENTATION OF CASE
An 86-year-old woman with known cholelithiasis presented to our office with one week of abdominal pain and nausea. X-rays taken at presentation demonstrated pneumobilia, and CT scan showed a 3.5 cm gallstone in the sigmoid colon. Medical management was unsuccessful in passing the stone, and a colonoscopy on day 4 was unsuccessful in incorporating the stone. Subsequent clinical deterioration prompted a laparotomy, where a perforation was discovered. A Hartmann's procedure was performed and the patient recovered after a complicated post-operative course.
DISCUSSION
Gallstone ileus is an uncommon, but medically important, cause of bowel obstruction. This presentation is considered a surgical emergency and thus prompt identification and removal is essential. Obstructions tend to occur in either the stomach or along the various segments of the small intestine but have been reported in the colon as well.
CONCLUSION
In cases of gallstones that manage to pass into the large intestine, it is prudent to attempt conservative measures for passage. Failure to do so should raise suspicion of a possible stricture, either benign or malignant, preventing its evacuation. Earlier surgical intervention should be considered in these cases.
doi:10.1016/j.ijscr.2014.11.058
PMCID: PMC4276087  PMID: 25498567
Colon; Sigmoid; Obstruction; Perforation; Gallstone
5.  Inflammation of the frontal intersinus septal air cell as a cause of headaches 
Highlights
•Surgery via the external approach appears to be an effective method in some cases.•ISSC is relatively often but rarely associated with pain.•In ISSC inflammation requires surgery as the only method of choice.
INTRODUCTION
The aim of this paper is to present a rare case of frontal intersinus septal air cell inflammation as a cause of headaches.
PRESENTATION OF CASE
A 23-year-old patient was admitted to the Department of Otolaryngology and Laryngological Oncology for severe headaches during an upper respiratory tract infection. After neurological consultation including brain MRI and CT scanning of the paranasal sinuses, the inflammation of the frontal intersinus septal air cell was diagnosed. After examination, the patient was qualified for external osteoplasty. Under general endotracheal anaesthesia, the frontal intersinus septal air cell was intraoperatively opened from the side of the right frontal sinus, the mucoid content was aspirated and a plate of bone was removed. The patient reported complete relief from headaches on the second day after surgery.
DISCUSSION
According to the previous studies, the frontal intersinus septal cell is more frequent in patients with frontal sinus inflammation than in the patients without inflammatory changes. Further, the conducted research indicates that its occurrence does not result in significant disorders in the drainage and ventilation of the frontal sinuses, and as such is not likely to be the cause of inflammation.
CONCLUSION
In the case of inflammatory changes in the frontal intersinus septal air cell without concomitant frontal or ethmoid sinusitis, surgery via the external approach appears to be an effective method for the radical removal of pathological changes.
doi:10.1016/j.ijscr.2014.10.064
PMCID: PMC4275785  PMID: 25485764
Inflammation; Air cell; Frontal intersinus septum; Headache
6.  Inflammatory myofibroblastic tumor of the small-bowel mesentery: A case report of nonspecific clinical presentation and a review of the literature 
Highlights
•Inflammatory myofibroblastic tumors most frequently arises from the lung.•Previously described in the literature as inflammatory pseudotumor, the current term for the condition is IMT.•There are a very small number of IMT in the small intestine mesentery cases reported in the literature.•The differential diagnosis of IMT includes reactive/reparative lesions and mesenchymal tumors of the gastrointestinal tract.•The principal therapy in patients with IMT is surgical resection.
INTRODUCTION
Inflammatory myofibroblastic tumor (IMT) is a rare neoplasm of various anatomical sites, which is histopathologically characterized by spindle-shaped cells with myofibroblastic proliferation and inflammatory infiltration.
PRESENTATION OF CASE
In this case report, a 37-year-old man presented with nonspecific systemic symptoms, including abdominal pain and weakness, which was diagnosed by multislice computed tomography and ultrasonography. An 8 cm × 5 cm × 5 cm nodular gray-white firm noninfiltrative mass, which was well localized in the mesentery tissues of small bowel, was observed and the patient underwent surgical resection.
DISCUSSION
A review of the literature on IMT of the small-bowel mesentery yielded a small number of previously described cases. This tumor most frequently involves the lungs and arises most commonly in extrapulmonary locations such as the mesentery and omentum. The etiopathogenesis and the clinical course of the disease are unclear. The histological and clinical differential diagnosis of IMT also includes reactive processes and mesenchymal tumors of the gastrointestinal tract. Follow-up after surgical removal documented local recurrence and metastasis.
CONCLUSION
The preferred primary treatment is complete surgical excision, and patients require close clinicoradiological follow-up. In general, cases treated with complete surgical resection have a good prognosis.
doi:10.1016/j.ijscr.2014.11.054
PMCID: PMC4275810  PMID: 25437679
Bowel; Inflammatory; Mesentery; Myofibroblastic; Small; Tumor
7.  Ischemic hepatitis after percutaneous nephrolitotomy: A case report 
INTRODUCTION
Ischemic hepatitis (IH) is the necrosis of the centrilobular hepatocytes of liver and is secondary to liver hypoperfusion in most of the cases. The diagnosis is usually based on biochemical findings due to the absence of symptoms and signs. Although the disease course is often mild, and sometimes is even not diagnosed, the outcome is poor if the etiology of hypotension and liver anoxia is not promptly corrected.
PRESENTATION OF CASE
A 64-year-old patient who underwent percutaneous nephrolithotomy (PNL) for right renal pelvic stone developed acute IH at first postoperative day as a result of hemorrhage related severe hypotension. After restoring hemodynamic parameters, she completely recovered 2 weeks after the operation.
DISCUSSION
IH is a frequent cause of marked serum aminotransferase elevation and most commonly occurs as a result of arterial hypoxemia and insufficient hepatic perfusion. Although no specific treatment of IH exists, stabilizing the hemodynamic parameters of the patient resolves the problem in most of the cases.
CONCLUSION
This case is presented to demonstrate that ischemic hepatitis should be kept in mind if severe hemorrhage occurs during PNL.
doi:10.1016/j.ijscr.2014.10.087
PMCID: PMC4275824  PMID: 25437690
Hemorrhage; Ischemic hepatitis; Percutaneous nephrolithotomy
8.  Multi-staged flap reconstruction for complex radiation thoracic ulcer 
INTRODUCTION
Chest wall reconstruction due to previous radiation therapy can be challenging and complex, requiring a multidisciplinary approach.
PRESENTATION OF CASE
The authors present the case of a 84-year-old woman with a right chest wall radionecrosis ulcer, that was submitted to an ablative surgery resulting in a full-thickness defect of 224 cm2, firstly reconstructed with a pedicled omental flap. Due to partial flap necrosis, other debridements and chest wall multi-staged flap reconstruction were performed.
DISCUSSION
This case highlights that the reconstructive choice should be individualized and dependent on patient and local factors. The authors advise that surgical team should work closely and be well versed in chest wall reconstruction with a variety of pedicled flaps, when a complication occurs.
CONCLUSION
A multi-staged flap reconstruction could be a salvage procedure for the coverage of complex, great and complicated chest wall defects due to previous radiation therapy.
doi:10.1016/j.ijscr.2014.11.041
PMCID: PMC4275858  PMID: 25437678
Chest wall; Flap; Radionecrosis; Radiation therapy; Thoracic ulcer
9.  Primary renal artery choriocarcinoma causing secondary renovascular hypertension 
Highlights
•Definition of a focus for a pregnancy of unknown location should use all clinical, laboratory data available.•Choriocarcinoma should be considered among the possibilities in the diagnosis of pregnancy of unknown location.•Radiological whole body imaging for this purpose should especially include FDG-PET.•Differentiating a nongestational choriocarcinoma may change the whole therapeutical approach.
INTRODUCTION
Choriocarcinoma is a rare primary germ cell tumour of the ovary composed of cyto- and syncytotrophoblast cells. Most of the choriocarcinomas are normally arising in the gestational trophoblast, gonads and, less frequently, mediastinum, pineal gland and retroperitoneum.
PRESENTATION OF CASE
We report a case of primary choriocarcinoma of renal artery causing secondary renovascular hypertension in a 28 years old woman of reproductive age, presenting with abdominal pain, minimal vaginal bleeding and a delayed menstrual period.
DISCUSSION
Non-gestational choriocarcinomas, are histologically related to the pregnancy related gestational choriocarcinomas. These two subtypes may have to be differentiated according the clinical and radiological findings and DNA analysis may be used for this purpose as well. In many studies, authors have stated that nongestational choriocarcinoma diagnosis could be implemented in situations where the presence of a pregnancy could not be considered like the prepubertal period.
CONCLUSION
Choriocarcinoma should as well be considered among the possibilities in the differential diagnosis of the causes for secondary hypertension, especially within a picture of pregnancy of unknown location, albeit being one of the rarest.
doi:10.1016/j.ijscr.2014.11.056
PMCID: PMC4275861  PMID: 25437675
Choriocarcinoma; Primary renal artery; Secondary renovascular hypertension; Pregnancy of unknown location
10.  Morgagni hernia treated by reduced port surgery 
Highlights
•Morgagni hernia is a rare diaphragmatic hernia and standard therapy has not been established.•The laparoscopic repair of a rare diaphragmatic Morgagni hernia in an elder patient using the reduced port approach is described.•This reduced port approach is a good indication for this type of hernia because of less invasive ness, cosmetics and safety.
INTRODUCTION
The laparoscopic repair of a rare diaphragmatic Morgagni hernia using the reduced port approach is described.
PRESENTATION OF CASE
An 85-year-old female presented with a 2 days history of upper abdominal discomfort and loss of appetite. We diagnosed her condition as a Morgagni hernia by morphological studies and performed laparoscopic mesh placement with a multi-channel port and 12-mm port. This elderly patient had a rapid postoperative recovery. A 2-year follow-up CT showed no recurrence of the hernia.
DISCUSSION
Recent trends in laparoscopic procedures have been toward minimizing the number of incisions to reduce invasiveness. This case indicated that the reduced port approach can be considered a suitable and safe procedure for treatment of Morgagni hernia.
CONCLUSION
The reduced port approach is a good indication for Morgagni hernia.
doi:10.1016/j.ijscr.2014.11.047
PMCID: PMC4275975  PMID: 25437681
Morgagni hernia; Reduced port surgery; Laparoscopic surgery
11.  A case of thrombocytopenia associated with the use of hydroxychloroquine following open heart surgery 
Highlights
•Thrombocytopenia is a common problem occurring in patients following cardiac surgery.•The researchers suggest that the use of hydroxychloroquine could be a rare of thrombocytopenia occurring after open heart surgery.•We present an unusual case of thrombocytopenia that was considered to be associated with the use of hydroxychloroquine in the late term following open heart surgery.
INTRODUCTION
Thrombocytopenia is a common problem occurring in patients and drug-induced thrombocytopenia is a significant cause of thrombocytopenia.
PRESENTATION OF CASE
We present an unusual case of thrombocytopenia that was considered to be associated with the use of hydroxychloroquine in the late term following open heart surgery.
DISCUSSION
The drug-induced thrombocytopenia, mechanical destruction of the platelets, and hemodilution are common causes of low platelet count. Although drug-induced immune thrombocytopenia has a mild clinical course in most cases (in this case it has severe clinical course), some patients may experience life-threatening hemorrhages. The decision to discontinue the drug that is deemed to be responsible from the drug-induced thrombocytopenia (DITP) relies on the clinical condition of the patient. The diagnosis is mostly established by discontinuation, exclusion, and correlation because the tests performed to detect drug-dependent antibodies (DDAbs) for the diagnosis of DITP are time-consuming, and these tests are also not commonly available. The authors of the current study diagnosed DITP by discontinuation of the drug. We suggest that the use of hydroxychloroquine could be severe thrombocytopenia occurring after open heart surgery.
CONCLUSION
The medication history must be carefully reviewed in patients presenting with thrombocytopenia, and if the medications could cause thrombocytopenia must be discontinued.
doi:10.1016/j.ijscr.2014.11.052
PMCID: PMC4276277  PMID: 25460494
Hydroxychloroquine; Cardiac surgery; Thrombocytopenia
12.  Right sided transmesentric hernia: A rare cause of acute abdomen in adults 
Graphical abstract
Highlights
•Right-sided transmesenteric mesocolic hernias are a rare cause of acute abdomen with few reported cases.•We report a 30-year-old male with right-sided transmesenteric hernia of ileum due to a congenital mesocolic defect.•The diagnosis of transmesentric hernia is purely by a CT scan.•Close monitoring of the patient is essential to identify the rare deteriorating patient for prevention of bowel gangrene.
INTRODUCTION
Transmesenteric mesocolic hernias are a rare cause of acute abdomen in adults with few reported cases in published literature.
PRESENTATION OF CASE
We report a rare case of a 30-year-old male with right-sided transmesenteric hernia of ileum due to a congenital mesocolic defect resulting in acute abdomen, presenting as acute abdomen. The hernia was reduced, small bowel inspected for gangrene and mesenteric hernia repaired, following which the patient made a good recovery and was discharged 5 days later.
DISCUSSION
The insidious onset of transmesenteric herniae and lack of specific radiological or laboratory investigations reaffirms the importance of surgeons maintaining a high index of suspicion for this surgical emergency.
CONCLUSION
Transmesentric hernia though rare can present as a case of acute abdomen in an emergency. The diagnosis is purely by a CT scan and close monitoring of the patient's general condition in cases of non-specific abdominal pain is essential to identify the rare deteriorating patient for early surgical intervention and optimal outcome.
doi:10.1016/j.ijscr.2014.11.037
PMCID: PMC4275791  PMID: 25437662
Internal hernias; Right sided transmesenteric hernia; Acute abdomen – colic; Adult; Intestinal obstruction; Gangrene
13.  Laparoscopic Nissen Rossetti fundoplication in situs inversus totalis—A blessing in disguise 
Graphical abstract
Highlights
•Situs inversus totals with dextrocardia can have both splenic and respiratory (ciliary) anomalies.•We have a case of hiatus hernia with situs inverses totalis.•We chose the laparoscopic nissen - rossetti fundoplication for this condition to minimise blood loss and post-operative gas bloating.
INTRODUCTION
Laparoscopic Nissen fundoplication and Nissen Rossetti fundoplication represent two different surgical approaches for treating hiatus hernia. We report a Laparoscopic Nissen Rossetti fundoplication (LNRF) for gastro esophageal reflux disease (GERD) in a patient with situs inversus totalis (SIT).
PRESENTATION OF CASE
: A 38-year-old man with SIT was diagnosed with sliding hiatus hernia. We performed Laparoscopic Nissen Rossetti procedure for this patient. The patient was discharged on first postoperative day after he tolerated oral liquids.
DISCUSSION
SIT is a rare anomaly presenting in 1–2 per 10,000 individuals. As this rare anomaly (SIT) led preoperative anticipation of respiratory and blood loss complications the above procedure was chosen. Less operating time, less calculated blood loss and improvement of symptoms with no associated gas bloating syndrome was noted especially with SIT.
CONCLUSION
We recommend relook into the Laparoscopic Nissen Rossetti fundoplication as an effective procedure in GERD especially with rare anomalies like SIT.
doi:10.1016/j.ijscr.2014.11.046
PMCID: PMC4275808  PMID: 25437677
Laparoscopy; Fundoplication; Situs inversus totalis; Gas bloating syndrome; Less intra operative times; Less blood loss
14.  Endoscopic excision of a lateral ventricular epidermoid—A case report of a novel technique 
Highlights
•Epidermoids of the lateral ventricle are relatively rare tumours.•As these tumours are soft and relatively avascular they appear to be ideally suited for endoscopic surgical excision.•Excision can be reliably attempted only in relatively soft avascular tumour of less than 2 cm in diameter.
INTRODUCTION
Epidermoids of the lateral ventricle are relatively rare tumours. As these tumours are soft and relatively avascular, they appear to be ideally suited for endoscopic surgical excision. At present the instruments available are specifically designed for endoscopic intra ventricular surgeries, limitations being inability to rapidly debulk the tumour and achieve adequate haemostasis. We present a case of lateral ventricular epidermoid that was excised endoscopically using a system originally designed for endoscopic disc surgery.
PRESENTATION OF CASE
We describe a female patient who presented with recurrent headache and occasional episodes of vomiting since 6 years. Preoperative diagnosis of lateral intra ventricular epidermoid was made with the help of an Magnetic resonance imaging (MRI) of the brain. Intraoperatively, an incision was made over the right Kocher's point and a 2.5 cm dural opening was made following a small craniotomy and the Destaudeau endoscope was introduced. A 30° scope and gentle manipulation were used to view the ventricular cavity and ensure near total excision of the tumour. Here we record this novel technique.
DISCUSSION
Lateral intra-ventricular tumours are usually approached through a trans-cortical or intra hemispheric approach, under microscope. The use of endoscopes have been largely restricted because of non-availability and relative difficulty in controlling troublesome bleeding, incase of vascular tumours.
CONCLUSION
A multi portal endoscope that allows use of routine pituitary instruments would enable the surgeon to achieve haemostasis effectively and, in our opinion, should be a viable alternative to microscope for excision of intra ventricular tumours.
doi:10.1016/j.ijscr.2014.11.039
PMCID: PMC4275816  PMID: 25437656
Lateral ventricular epidermoid; Endoscopic excision
15.  A case report: Cecal volvulus caused by Meckel's diverticulum 
Highlights
•Although, MD is the most common congenital condition of the GI tract, the clinical diagnosis of MD is difficult to make.•Most cases of MD are found incidentally during a surgical procedure for another reason.•The mainstay treatment would be resection of the diverticulum or the segment of the bowel affected by the pathology.
INTRODUCTION
Meckel's diverticulum is the most common congenital anomaly of the small intestine. Common complications related to Meckel's diverticulum include hemorrhage, intestinal obstruction and inflammation. Acute large bowel obstruction is a rare complication of Meckel's diverticulum and in the presented case it is caused by volvulus.
PRESENTATION OF CASE
We report a 39 year old female who presented with the diagnosis of a large bowel obstruction occurring as a result of cecal volvulus caused by adhesions of a perforated diverticulum.
DISCUSSION
The reported case presents one of the rare complications of MD, which is volvulus. The case described above presented with signs and symptoms suggestive of acute intestinal obstruction and radiological findings suggestive of cecal volvulus. The patient was taken to the operation room for exploration and we discovered the presence of a perforated MD. The main treatment of such case is to perform diverticulectomy in all symptomatic patients.
CONCLUSION
MD is mostly identified intraoperatively. Knowledge of the pathophysiologies by which MD can cause complications such as volvulus is important in order to plan management.
doi:10.1016/j.ijscr.2014.11.038
PMCID: PMC4275830  PMID: 25460488
Meckel's diverticulum; Cecal volvulus; Volvulus
16.  Penetrated sigmoid colon by air gun pellet could be life threatening: A case report 
INTRODUCTION
Air and paintball guns have been in existence for over 400 year. Although serious injury or death can result from the use of such guns, previous literature has not mentioned the issue of the penetration of the sigmoid colon by an air gun pellet.
PRESENTATION OF CASE
We report a rare case of a 44-year-old Caucasian woman referred to abdominal surgery after an accidental small wound had occurred in the lower left abdominal quadrant that was caused by an air gun pellet. The blood and biochemical analyses were normal but the CT scan revealed the presence of a foreign body – an air gun pellet in the left iliac region of the abdomen. Clinically, during the initial 24 h significant changes were not noticed. After 42 h, however, pain and local tenderness in the lower left abdominal quadrant was expressed. A laparotomy revealed a retained pellet in the wall of the sigmoid colon and a small leak with colonic content with consecutive local peritonitis also occurred. The foreign body was removed and the opening edges in the colon were excised and closed with the primary suture.
DISCUSSION
The hollow organs of the digestive tract, albeit very rarely penetrated by an air gun pellet, do not typically show all signs of an acute abdomen in the early posttraumatic phase. Such injuries can lead to a pronounced infection, which may cause septic shock if not appropriately treated.
CONCLUSION
For correct diagnosis, a careful approach and several daily clinical observations are required.
doi:10.1016/j.ijscr.2014.11.043
PMCID: PMC4275851  PMID: 25437671
Air gun pellet; Sigmoid colon perforation; Peritonitis
17.  Pancreatic neuroendocrine tumor with splenic vein tumor thrombus: A case report 
Highlights
•Pancreatic neuroendocrine tumors are rare malignancies.•Nonfunctional pancreatic neuroendocrine tumors are often diagnosed in advanced stages.•Venous tumor thrombus may be associated with pancreatic neuroendocrine tumors and current preoperative imaging is often inaccurate in predicting the presence or absence of venous tumor thrombus.
INTRODUCTION
Pancreatic neuroendocrine tumors (PNET) are rare, often indolent malignancies. PNET are classified as functional or nonfunctional based on the secretion of hormones without a negative feedback loop; the latter account for up to 60% of PNET. Although PNET are associated with a better prognosis compared to pancreatic adenocarcinomas, they are often diagnosed in advanced stages, making them a significant source of morbidity for patients. Here we present a rare case of venous tumor thrombus arising from a nonfunctional PNET.
PRESENTATION OF CASE
A 44-year-old woman was referred for evaluation and treatment of a possible tail of pancreas PNET discovered during work-up for a 9 year history of intermittent subcostal pain. Previous endoscopic ultrasound with fine needle aspiration revealed a 3.5 cm × 3 cm mass, with cytological diagnosis of neuroendocrine tumor. Patient was scheduled for laparoscopic distal pancreatectomy. During surgery the mass was found to encase the splenic vein leading the surgeon to perform an en bloc distal pancreatectomy and splenectomy. Pathologic analysis revealed a 1.8 cm × 5 cm tumor thrombus lodged in the splenic vein.
DISCUSSION
Nonfunctional PNET usually present in advanced stages and can be associated with venous tumor thrombi. Preoperative imaging may not accurately predict the presence of venous tumor thrombi.
CONCLUSION
En bloc resection of primary tumor, involved organs and thrombus is the recommended treatment option and often results in long term survival. New multi-modality strategies are needed for detection of venous involvement in nonfunctional PNET to better assist with preoperative planning and counseling.
doi:10.1016/j.ijscr.2014.11.045
PMCID: PMC4275856  PMID: 25460491
Neuroendocrine tumor; Pancreatic tumors; Venous tumor thrombus; Non-functioning pancreatic neuroendocrine tumor; Pancreatic neuroendocrine tumor
18.  Clinical and surgical management of unilateral prepubertal gynecomastia 
Highlights
•We present an otherwise healthy boy of 12 years old with unilateral breast masses. No abnormalities were found on ultrasonography and on all endocrine parameters.•We present a new “modified” Webster technique. The results confirmed validity of this technique in terms of esthetic and functional results, and patient satisfaction.•The evaluation of unilateral gynecomastia can therefore be complex.•The surgical treatment of unilateral gynecomastia requires an individual approach, based on an appropriate diagnostic algorithm.
INTRODUCTION
Gynecomastia is the benign proliferation of the glandular tissue in the male breast. This condition is thought to be caused by the imbalance between estrogen action relative to androgen action at the breast tissue level. Bilateral gynecomastia is frequently found in the neonatal period, early in puberty, and with increasing age. Prepubertal unilateral gynecomastia in the absence of endocrine abnormalities is extremely rare, with only a few cases in literature.
PRESENTATION OF CASE
We present an otherwise healthy boy of 12 years old with unilateral breast masses. No abnormalities were found on ultrasonography and on all endocrine parameters. Treatment consisted in a new “modified” Webster technique.
DISCUSSION
The results confirmed validity of this technique in terms of esthetic and functional results, and patient satisfaction. Atypical presentations of gynecomastia are often not recognized. The main pathophysiology of gynecomastia is alteration in the balance between the stimulatory effect of estrogen and the inhibitory effects of androgens on the development of the breast. If there is no causal treatment, surgical resection is the therapy of first choice.
CONCLUSION
The exact mechanism of unilateral gynecomastia formation in our case is unclear. The evaluation of unilateral gynecomastia can therefore be complex. In conclusion, the surgical treatment of unilateral gynecomastia requires an individual approach, based on an appropriate diagnostic algorithm.
doi:10.1016/j.ijscr.2014.11.040
PMCID: PMC4275969  PMID: 25437663
Unilateral gynecomastia; Radical mastectomy; Adipose tissue pedicle; Diagnostic algorithm
19.  High grade angiosarcoma fifteen years after breast conservation therapy with radiation therapy: A case report 
Highlights
•We examine a case of secondary angiosarcoma of the breast fifteen years after original treatment.•Introduction into secondary or radiation induced angiosarcoma of the breast.•Discussion of the case reports for secondary angiosarcoma of the breast.
INTRODUCTION
Angiosarcoma is a rare tumor of the breast. Secondary angiosarcoma of the breast refers specifically to a tumor that arises after a latency period following radiation. With breast conservation therapy gaining significant popularity to that of mastectomy, more cases of secondary angiosarcoma continue to arise in the irradiated fields of these patients.
PRESENTATION OF CASE
The authors describe the case of an 80 year old female who presented fifteen years after her surgery and radiation treatment with two bleeding skin lesions in her breast. These lesions were found to be high grade angiosarcoma upon excision. Due to high cardiac co-morbidity she was treated with re-excision and surveillance.
DISCUSSION
This case is an example of a rare sequela to a common procedure. Breast conservation therapy with lumpectomy and radiation has become a popular technique in treating localized breast cancer. Radiation like all therapy has its known adverse effects. Further work is needed with the small amount of published cases of angiosarcoma after breast irradiation so that we may find optimal treatment plans for these patients. Like any rare entity, difficulty lies in accruing enough cases to compare prognosis and results.
CONCLUSION
Secondary breast angiosarcoma diagnosis requires frequent follow ups and a high index of suspicion. With mastectomy giving the best chance of treatment in these cases, early detection is crucial in this rare sequela.
doi:10.1016/j.ijscr.2014.11.042
PMCID: PMC4276049  PMID: 25437669
Angiosarcoma; Radiation therapy; Breast cancer; Radiation induced neoplasm; Breast surgery
20.  Microspheres embolization of juvenile nasopharyngeal angiofibroma in an adult 
INTRODUCTION
Juvenile nasopharyngeal angiofibroma (JNA) is a benign though locally aggressive, highly vascular tumor primarily affecting adolescent males which has traditionally posed a significant intraoperative challenge during its resection due to the high risk of uncontrollable hemorrhage. Pre-operative angiographic embolization of the major feeding vessels to the tumor has become a valuable, even necessary, tool in the surgical treatment of these lesions.
PRESENTATION OF CASE
Our patient was a 32-year-old man with a chief complaint of recurrent left-sided epistaxis for one year, brisk and continuous for ten days prior to presentation, subsequently found to have a 4 cm vascular skull base tumor causing mild expansion of the pterygopalatine fossa. The patient underwent pre-operative embolization utilizing 300–500 micrometer microspheres injected into the ipsilateral maxillary artery. The following day, the patient underwent definite Stereotactical surgical resection of his JNA tumor. Estimated blood loss during the operation was 50 mL, and the patient was discharged the same day.
DISCUSSION
Juvenile nasopharyngeal angiofibromas pose a significant bleeding risk for the surgeon due to their highly vascular nature. Pre-operative embolization of juvenile nasopharyngeal angiofibromas can reduce intraoperative blood loss while lessening the risk of massive hemorrhage, shortening operation times, increasing intra-operative visibility, and allowing for easier resection of lesions.
CONCLUSION
Pre-operative embolization of JNA is a safe, effective method to prevent against the risk of massive, sometimes fatal, hemorrhage that occurs with these highly vascular tumors.
doi:10.1016/j.ijscr.2014.10.019
PMCID: PMC4276082  PMID: 25437676
Juvenile nasopharyngeal angiofibroma; Embolization; Tumor; Interventional; Radiology; Microsphere
21.  Aerosol steroids for the treatment of peristomal mucocutaneous breakdown due to severe eczema 
Highlights
•First line treatment for localised peristomal eczema is topical steroids.•Oil based topical steroids are associated with reduced bag adherence.•Alcohol based topical steroids are poorly tolerated due to pain.•Aerosol steroids are well tolerated.•Aerosol steroids do not impact on stoma bag adherence.•Aerosol steroids have fewer side effects in comparison to systemic steroids.
INTRODUCTION
We describe a novel treatment of mucocutaneous peristomal junction breakdown in a patient with severe eczema using aerosol steroids, where conventional methods failed to achieve healing.
PRESENTATION OF CASE
Observation and photographic evidence showing resolution of severe peristomal eczema in a patient, in whom systemic steroids were contraindicated, using a topical aerosol steroid. We found complete resolution of peristomal eczema and symptoms within four weeks.
DISCUSSION
Topical aerosol steroids are better tolerated than alcohol based steroid preparations, achieve improved stoma appliance adherence in comparison to oil based steroid preparations and reduce systemic side effects in comparison to systemic oral steroids.
CONCLUSION
Aerosol steroids appear to be a safe and effective way to treat refractory peristomal eczema and may be of use in other peristomal inflammatory conditions including contact dermatitis.
doi:10.1016/j.ijscr.2014.11.015
PMCID: PMC4276280  PMID: 25437668
Stoma; Peristomal; Eczema; Inhaled steroids; Aerosol steroids
22.  Paraduodenal herniation: An internal herniation in a virgin abdomen 
Highlights
•A paraduodenal hernia is an uncommon hernia that results from an abnormal rotation of the midgut.•Early diagnosis is imperative in order to avoid bowel ischemia, which is associated with high mortality.•We present a case of a left-sided paraduodenal hernia in a virgin abdomen with a herniation of a loop of jejunum through a defect of the posterior portion of the ligament of Treitz.•Treatment includes exploratory laparotomy, repair and reduction of the hernia, and laparoscopic repair.
INTRODUCTION
A paraduodenal hernia is an uncommon hernia that results from an abnormal rotation of the midgut. Commonly, these hernias are congenital in nature, and are reported to cause 1.5–5.8% of intestinal obstructions. These hernias occur when a part of the jejunum herniates through the posterior portion of the ligament of Treitz. Diagnosing these hernias preoperatively has been shown to be difficult, despite the studies that are available. Early diagnosis is imperative to the patient in order to avoid strangulation of the bowel, which is associated with a high mortality.
PRESENTATION OF CASE
In this case, we present a case of a left-sided paraduodenal hernia in a virgin abdomen in a 38-year-old African American male with a herniation of a loop of jejunum through a defect of the posterior portion of the ligament of Treitz. The patient also had a volvulized segment of the proximal jejunum, and part of this bowel was found to be ischemic.
DISCUSSION
Acute intestinal obstruction caused by a left paraduodenal hernia is a rare cause of intestinal obstruction. A literary search of PubMed between 1980 and 2012 indicated only 44 cases of intestinal obstruction secondary to a left paraduodenal hernia.
CONCLUSION
The patient underwent exploratory laparotomy, and the herniated bowel was found to be ischemic. The hernia was reduced, and the ischemic bowel resected. The defect was closed, and the patient had a non-complicated recovery.
doi:10.1016/j.ijscr.2014.11.021
PMCID: PMC4275822  PMID: 25437660
Paraduodenal hernia; Ligament of Treitz
23.  Post-splenectomy intrapancreatic accessory spleen mimicking endocrine tumor of the pancreas 
Highlights
•The first case of IPAS arising after splenectomy.•The IPAS has similar features of pancreatic neuroendocrine tumor on images.•Typical pathologic data and characteristics of IPAS were presented and described.•A brief review of IPAS was included.
INTRODUCTION
Intrapancreatic accessory spleen is an uncommon congenital abnormality of the spleen with no indication for surgical intervention. Among the few cases reported, IPAS coexisted with a normal spleen. We here report the first case of IPAS arising a couple years after splenectomy with the appearance of an endocrine tumor of the pancreas.
PRESENTATION OF CASE
A 62-year-old female presented with a one-week history of left upper quadrant discomfort. She had splenectomy for the treatment of hypersplenism caused by cirrhotic portal hypertension two years before this admission. Her physical examination was unremarkable and laboratory data was within the normal range. Both the ultrasonography and magnetic resonance image revealed a small oval-shaped mass in the tail of her pancreas with the diameter 2 cm or less. A distal pancreatectomy was performed for the suspection of malignant neuroendocrine tumor of the pancreas. An intrapancreatic accessory spleen was confirmed by the pathologic examination.
DISCUSSION
Intrapancreatic accessory spleen is one kind of congenital ectopic spleen without indication for operative intervention. We present the case to support that intrapancreatic accessory spleen may enlarge through a compensatory mechanism, and raise the awareness of this intrapacreatic entity to avoid unnecessary surgical operation.
CONCLUSION
IPAS should be highly considered as a differential diagnosis while the lesion is no more than 2.5 cm in diameter and/or other accessory spleens show around the splenic hilum.
doi:10.1016/j.ijscr.2014.11.032
PMCID: PMC4275968  PMID: 25437661
Intrapancreatic accessory spleen; Pancreatic neuroendocrine tumor; Splenectomy; Pancreas
24.  Abdominal wall hernia and aortic injury secondary to blunt trauma: Case report and review of the literature 
Highlights
•Traumatic abdominal wall hernias (TAWHs) and traumatic abdominal aortic injuries (TAAIs) are complications of severe blunt trauma.•CT is a sensitive imaging modality to detect TAWHs.•As only severe TAAI will have positive physical exam findings, imaging techniques, surgical exploration, or on-table angiogram may aid in diagnosis.
INTRODUCTION
Traumatic abdominal wall hernia (TAWH) and traumatic abdominal aortic injury (TAAI) are two uncommon complications secondary to blunt trauma. In both TAWH and TAAI, reported cases are often associated with poly-trauma. TAWH may be initially missed if more pressing issues are identified during the patient's primary survey. TAAI may be an incidental finding on imaging or, if severe, a cause of an acute abdomen and hemodynamic abnormality.
PRESENTATION OF CASE
A 54-year-old white male suffered a TAWH and TAAI (pseudoaneurysm) due to severe blunt trauma. TAWH was apparent on physical exam and the TAAI was suspected on computed tomography (CT). The patient's TAWH was managed with a series of abdominal explorations and the TAAI was repaired with endovascular stenting.
DISCUSSION
TAWH and TAAI are commonly due to severe blunt trauma from motor vehicle collisions. Diagnosis is made through physical exam, imaging studies, or surgical exploration. A variety of surgical techniques achieve technical success.
CONCLUSION
The patient with blunt trauma to the abdomen is at risk for TAWH and TAAI, which are often associated with other injuries. Investigations should include thorough clinical exam through secondary survey and radiologic imaging in the hemodynamically normal patient.
doi:10.1016/j.ijscr.2014.11.036
PMCID: PMC4276255  PMID: 25437685
Traumatic abdominal wall hernia; Blunt abdominal trauma; Trauma surgery; General surgery; Blunt abdominal aortic injury; Abdominal aortic pseudoaneurysm
25.  Floating thumb with double dislocation of carpometacarpal and metacarpo-phalangeal joints 
INTRODUCTION
Double dislocations of carpometacarpal and metacarpo-phanlageal joints are rare. We report an unusual case of simultaneous dislocation of both CMC and MCP joints in the thumb.
PRESENTATION OF CASE
A 31 year old male was admitted following a road traffic accident. He was complaining of pain and deformity of right thumb. The X-ray examination revealed simultaneous dislocation of both CMC and MCP joints. He underwent closed manipulative reduction and percutaneous K wire fixation. The wires were removed after six weeks. After a course of physiotherapy he regained full range of pain free movements.
DISCUSSION
The incidence of simultaneous dislocation of both CMC and MCP joints in thumb are associated with high energy injuries. The options of treatment are conservative with cast immobilisation and serial X-rays or operative including closed manipulative reduction and K wire fixation or open reduction and internal fixation.
CONCLUSION
The option of treating this rare injury with closed manipulative reduction and percutaneous K wiring gives excellent and predictable results.
doi:10.1016/j.ijscr.2014.11.031
PMCID: PMC4276275  PMID: 25437649
Double; Dislocation; Carpo-metacarpophangeal; Metacarpo-phanlangeal

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